HLOL Podcast Transcripts

Health Literacy

Health in Context of People’s Lives (HLOL #244)

Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z. I also produce and host this podcast series, Health Literacy Out Loud.

Today’s guest is Rear Admiral Paul Reed, who is the United States Deputy Assistant Secretary for Health and the Director of the Office of Disease Prevention and Health Promotion. He also is a pediatrician and a senior US Public Health Service Officer.

His primary responsibility is to advise the Assistant Secretary for Health on disease prevention and health promotion programs and policies.

Additionally, Paul Reed provides direction and oversight for national health initiatives such as Healthy People 2030, the Dietary Guidelines for Americans, the Physical Activity Guidelines for Americans and the President’s Council on Sports, Fitness and Nutrition.

He also is a champion of health literacy and has written several blogs on the topic.

Welcome to Health Literacy Out Loud.

RDML Paul Reed: Thank you, Helen. It’s a pleasure to be here. I very much appreciate the opportunity to talk with you today.

Helen Osborne: That’s certainly likewise on my end. As you and I were getting ready for this podcast, we had some conversations about, “What do we mean by the term health?” You said that it’s really important to consider health in context of people’s lives. Tell us more about health in context of people’s lives.

RDML Paul Reed: I think at the center of the way I look at all this, and I’ve been looking at health from a number of different angles for many years now, I’ve come to take the position that we find health individually for ourselves and for our loved ones in the environments where we live.

As the social determinants of health framework would suggest, or offers as a way of thinking about it and framing it, it’s where we live, where we work and play, where we’re born, where we grow and where we age. I believe that to be firmly true.

Counter to that, or perhaps misaligned with that theory, is the idea that the healthcare system that we traditionally think of is where we need to go to get healthy. But I would argue that that’s where we go to get better.

We don’t necessarily have a healthcare system that’s designed to encourage health and to be healthy, but we certainly have an ideal healthcare system to treat us when we are unhealthy and diseased.

Helen Osborne: Certainly, that’s been a part of your life for many years. You’re a practicing physician, a pediatrician. I have a clinical background, too. But we only see people when they’re not at their best, when they’re not feeling well, when they’re ill.

RDML Paul Reed: Generally so, but I think there’s a good portion of primary care, and certainly it’s true for primary pediatric care, that we take care of children growing up in a preventive medicine model.

But if you think about it, even that preventive medicine model is one that’s disease-centric. We’re preventing something, as opposed to health promoting. Health promotion in my mind goes far beyond the traditional framework or models of disease prevention.

Even in a very holistic primary care setting, there’s only so much that a clinical environment can do for patients and for families that touches on those core aspects of their lives that influence their health, such as education, good nutrition and adequate housing. Those things are outside the realm of control of the traditional healthcare system.

I know in this day and age we actually are moving through some models in healthcare that are supposed to expand on our ability as clinicians in clinical settings to coordinate and work with our patients to help benefit those social determinants of health.

But ultimately, I feel like that’s an inordinate challenge for the healthcare system, which is already overly burdened in its disease care, to actually help and really influence those kinds of changes that are meaningful in people’s lives where they live.

Helen Osborne: I’m also thinking of the time proportion. For the amount of time a patient is with a provider, and I’m putting that in a medical sense, for most people that’s a very tiny little fraction of their lives.

When you talk about the environment in which we work, play, live and age, that’s what happens all the other times of our lives.

RDML Paul Reed: There’s a model that was used by several of my mentors in years past called the life space, or the whitespace. What that model was meant to represent is the sum total on average in the number of minutes or hours that an individual encounters the healthcare system.

That can be everything from being in the operating room having surgery to meeting with your pharmacist and picking up a prescription, or meeting with your primary care provider in a clinical setting, and everything else.

But the average for the typical American citizen, that amount of time can be measured literally in hours at best per year, whereas everything else, all the other time that an individual spends out there in the world, is well outside the healthcare system.

If you think of that model itself, the life space or the whitespace, being all that other area where we are experiencing the world, then it makes sense that how we ensure our health needs to be looked for in those places.

Helen Osborne: Is this a very different mindset or philosophic shift from the way we’ve been thinking about healthcare, which is caring for people?

I know the initiatives that you are overseeing, Healthy People 2030 and the Dietary Guidelines and Physical Activity. Is this a huge shift in how we’re envisioning health?

RDML Paul Reed: I think philosophically it certainly is. In fact, it goes even further beyond those aspects that you just mentioned that are unique to my office, or that certainly are the mandate of my office.

Yes, I think it demands that philosophical mind shift. We have to frame the way we look at where we need to find the things that help us be healthy.

Nutrition is probably one of the best examples. It’s certainly one of the best examples of social determinants that’s getting the most attention these days. But nutrition is just one aspect of our lives.

If you want to entertain how much time we spend engaged with eating and the procurement of food, it’s, again, only a percentage of our life.

Helen Osborne: A bigger percentage than the amount of time we’re at a doctor’s appointment probably.

RDML Paul Reed: That is for sure, yes.

Helen Osborne: Can I ask you a question? You’ve used the term several times out there, about social determinants of health. Could you explain that a little bit, and maybe expand on how that fits in with this greater philosophy of health in context of people’s lives?

RDML Paul Reed: Sure. There’s a legacy of the framework of the social determinants of health that’s been around for decades now, and we employ it through the Healthy People initiative overtly.

Healthy People is very much built around the social determinants of health framework, and there is much about it that resonates with the philosophy I’m talking about.

However, there’s also this other aspect to the legacy of how social determinants of health as a framework has been employed in the health systems, in the public health system in particular, and now as we are entertaining it more often in the clinical healthcare system.

I would argue that it’s actually more couched in terms of the social determinants of ill health, in more negativistic terms. We have historically employed the framework of SDOH to really look at those things that make us unhealthy and try to address them in that manner.

Helen Osborne: Can you give some examples, please?

RDML Paul Reed: Housing is probably one of the best ones, or one of the worst ones depending on how you look at that. We know that the living conditions that people have, both in and around their homes, is a great determinant of how healthy they are able to be.

But frankly, we think of that almost exclusively in the negative sense. We talk about those aspects of a person’s home that contribute to their asthma or that exacerbate their underlying health conditions otherwise, such as chronic obstructive pulmonary disease, and how a home environment can exacerbate that condition. That’s just a couple of examples.

What we don’t do, and what I think we need to do under this new philosophy, if you will, is think about the home as an enabler for healthy lifestyles and look to those conditions within which we live, and around our home lives, where we’re able to do things like breathe better, move more effectively to benefit ourselves and cook healthier meals with more nutritious food.

Those are positive qualities, and I would argue that those are true social determinants of health.

There’s actually a more expansive model that’s now being adopted. Certainly in civil society it’s being adopted. We actually are leveraging that framework in the federal government as we speak, which is more positive framing and it’s more expansive in terms of how inclusive it is with all of those conditions of our lives.

That framework is historically known as the Vital Conditions for Health and Well-Being. But more contemporarily, particularly outside of government, that framework is now being referred to as the Vital Conditions for Well-Being and Justice to be all the more inclusive of those various aspects of our lives that influence our health and have the potential to favorably influence our health.

I particularly emphasize that latter point because that, like the more expansive, more inclusive approach that the Vital Conditions framework has to that which historically the social determinants of health framework has employed, is really what it’s all about.

It’s about thinking about things positively, openly and with as much inclusivity as possible to all of those facets of our lives that encourage healthy lifestyles, and I should also say enable them. Not just encourage them, but actually enable us to be healthier.

I’ve been blessed, and I would venture to guess that you, too, have been blessed in your life circumstances to have the ability to lead a healthier life, being able to afford good nutrition, having access to good nutrition, being able to go out and walk in the environment around your home, things that many of us take for granted, but many of us in this country have really no access to.

I think if we look at those disparate circumstances that people face, the true inequity that’s out there, and we frame improving upon those inequities through this Vital Conditions lens, optimizing people’s living conditions . . .

Helen Osborne: I want to go for an example. You’re right. I’ve been blessed in that way. I can go for my walk, and I can open the fridge, there’s sufficient food in there and I can find some things that are healthy. Walking is a large part of my life.

RDML Paul Reed: I’m glad to hear that.

Helen Osborne: I walk miles every day, as many days as I can. How would you turn it into a positive for someone who perhaps does not feel safe walking outside, may not have sidewalks or for other life circumstances, like disability or time, may not be able to go for that walk? How would you flip that and turn that into more of a positive?

RDML Paul Reed: I would say for those of us in service to people in those circumstances, it behooves us not to think about the problems they face, but the solutions that would engender better opportunity for them.

Rather than describing the issues that they face in a negative light, why not describe what needs to be done in a positive framing, such that they then gain those opportunities? They have the enabling environment instead of the disabling environment.

That’s where, at the federal level, we’d like to see policy shifting its frame of reference to. Rather than saying we’re going to devise policies, regulations and funding opportunities out of the federal government that undo the bad things that exist in the world, that disable people in their ability to thrive and live healthfully, it’s that little bit of a brain shift to say, “Through aspects of Vital Conditions that improve upon people’s lives, what is it we can do? How is it we can apply these resources?”

All the same resources we’re talking about that have historically existed, how can we turn them around to enable, to improve, to gain those positive characteristics of people’s environments and lives?

It sounds subtle, but it’s not. It’s actually rather profound when you think about it, especially if you spend any amount of time working in federal government.

Helen Osborne: I want to hear about what the federal government is doing to make a big difference. But again, making this more local, in my town we’ve had a group of volunteers and people living nearby who have turned our rails into trails.

It’s a very accessible walk. In fact, I was there just this week and people are walking, in wheelchairs, baby strollers, all kinds of ways.

There was even an initiative that set up making bicycling happen for people, whatever they brought to it. They wanted to make this possible for people to go biking in some semblance on our local rail trail. Is that what you’re talking about?

RDML Paul Reed: Yes, it’s exactly what I’m talking about. It’s what we can do, not what we are inhibited from doing. That’s the philosophical shift.

Again, it sounds subtle, but it’s just having that frame of reference, that frame of mind about what we can do within our power, within the resources available to us, at whatever scale of government or community, and starting from that position and saying, “Recognizing that this, that or the other thing within the Vital Conditions framework benefits our life, let’s go about tackling those things within our power to do so.”

Key to that is having a sense of community. I think you alluded to it in that example you just gave. There was a rallying, if you will.

It’s what the actual Vital Conditions framework would call a civic muscle, where individuals and communities leverage their influence on the resources available to them or seek out resources outside their immediate availability through this civic muscle.

That comes in various forms. It comes from having a voice. It comes from having a seat at the table to use that voice. It comes from the power of voting. All these things are aspects of one’s civic muscle both as an individual and as a community that can translate all those other things into favorable circumstances.

Helen Osborne: You talked about what we can be doing. You are at this very high senior level of US federal policy. I want to know how you and organizations you work with, not just you individually, are working to help shift this philosophic mindset.

But we’re not at the level you’re at, most of our listeners. I want to know what we, as people who just care about health and wellness and our people we care for and care about, can be doing, whether we are practicing as clinicians, in public health, in community organizations or just caring.

That’s a big ask I’ve got to you, so take it from the top. What are you and colleagues doing at the federal level to make this happen?

RDML Paul Reed: In all honesty, we’re playing catch-up. That’s what we’re doing.

There’s a great deal of this type of activity taking place out there in communities all around this country, and there are actually organizations at the national level in civil society that are trying to organize all of that community-centric effort, again framed off of this framework of the Vital Conditions for Well-Being and Justice.

The federal government is playing catch-up to that way of speaking about things and understanding needs of individuals and communities better, but doing so within the organization of the federal government.

In other words, through the pandemic, one of the things that was asked of the federal government was to consider how we could recover from the pandemic in all the facets of our lives and in governance that were impacted by the pandemic, but then how we could go well beyond that.

Frankly, the implications on the federal government were well past whatever recovery was going to look like in how the federal government thinks about building resilience.

It was that ask through the early phases of response to the pandemic, and through the latter phases of recovery through the pandemic, that the dialogue started around resilience-building as a key quality of federal government’s responsibilities.

It’s not to say the term resilience hasn’t been around for a while. In fact, we did a look-see at how many times the term “resilience” was used in the federal government a little over a year and a half ago, I think.

We discovered about 80 different definitions of resilience, because the word was being used that much around the government.

What wasn’t true about the concept of resilience in the federal government was an orchestrated, unified approach to thinking about it and measuring it, considering all facets, all corners of government, that is, and considering what individual roles they had to play that rolled up to building resilience at the community level.

We actually developed a federal plan around that, and we have a set of recommendations on how any agent within the federal government can pick up this federal plan and this framework of the Vital Conditions for Well-Being and ask, “How can I, with the tools I have available to me, better apply those tools toward meaningful outcomes in people’s lives as defined in the framework of the Vital Conditions?”

This is all, by the way, in harmony with civil society, to your question. It isn’t that the federal government needs to be doing this in a vacuum.

It needs to be doing it harmonized with all those aspects out there in civil society that are ongoing to understand needs in communities better, and by extension I mean needs of individuals within those communities, and the relationship of those needs more directly to the resources that the federal government can bring to bear, and vice versa.

Individuals, communities and civil society actors, be they community-based organizations, philanthropies, local governments, etc., can better relate their understanding at those discrete levels of community to where the needs are and be able to better access them. It’s really a two-way street.

Helen Osborne: I’m so glad you’re looking at those complementary components, and I just want to thank you on behalf of all the federal policy there about this orchestrated approach.

It has made a huge difference, I know, in my world of health literacy by reframing the definitions, what we mean about that, by changing the philosophy and by providing some tools.

Just today, I was looking at some discussion list I’m on about health literacy and someone is referencing some federal tools they use in their community.

I love how we’re all working on this one together, and I’m thrilled that you are helping lead the way in doing this overall policy.

RDML Paul Reed: One of the things we talk about in Healthy People 2030 is how health literacy is both for the individual and the organization.

Helen Osborne: I admire that. I’m so pleased that you include both of those tandem definitions.

RDML Paul Reed: I think what you describe in this harmonization, complementarity, orchestration and philosophical reframing that we’re going through not just in the federal space, but in concert with society, is getting exactly at that point.

Improving upon health literacy is true for me individually. I need to do that for myself, just as you do and each and every one of us needs to.

But organizationally, in every kind of way organizations exist, those organizations, including as big an organization as the federal government, need to have an understanding of its responsibility toward improving its own health literacy, and helping to improve the health literacy of others.

I think by the idea of not just talking about health, but talking about wellbeing, and even the more expansive concepts of thriving and resilience, that helps us further along all of our health literacy.

Inherent in resilience and being able to thrive and being well is being healthy.

Helen Osborne: What gives you joy about doing this, about trying to change a whole philosophy? That’s a big job. What gives you the joy about it?

RDML Paul Reed: I’ve never been faulted for not thinking strategically and big picture. Let me tell you that. In fact, it’s often I’ve been criticized for having my head in the clouds too often, too much.

But at this point in time in my career, as well as I think at this point in time given what has happened for all of us through the pandemic . . . and I mean that in a good way. A raised consciousness and understanding about the importance of our health, and in some nuanced, if subtle or not-so-subtle ways, an understanding of how our life circumstances play out in our health, we all have gained insights into that through the pandemic to some degree or another.

At this point in time, in my mind, we have to capitalize on that. We have to take advantage of that raised consciousness individually and collectively in this country and around the world and put these kinds of ideas and opportunities to evolve out there. That excites me. It’s an unprecedented time in that respect. I really believe that.

At some point, my career has to come to an end and I have to walk away and say, “I gave it my best try.” Right now, I feel like I’m giving it my best try in helping to elevate this kind of new philosophy, if you will.

Helen Osborne: I agree with you. Thank you for encouraging us as individuals to flex our civic muscle and for doing so at this large federal policy level. You’re just a joy, and I hope you keep doing this for a long time. Thank you, thank you, thank you for being a guest on Health Literacy Out Loud.

RDML Paul Reed: It’s been a pleasure talking with you, Helen. Truly.

Helen Osborne: As we just heard from Rear Admiral Paul Reed, it is so important to consider health in context our lives. But doing so is not always easy.

For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loud interviews come out the first of every month. Get them all for free by subscribing at www.HealthLiteracyOutLoud.com, or wherever you get your podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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